How Do Insurance Claims Work in Florida?

In Florida, an insurance claim is an official request for compensation by a policyholder or their authorized beneficiary to an insurance company when covered losses occur. Insurance claims can be filed to receive survivor (death) benefits, settle medical bills or accident-related expenses, and cover repairs for property damage, among others. Typically, the insurer reviews a claim to ensure that the information supplied is valid before approving the payment of compensation. The insurance company can also deny a claim if the information evaluated is invalid.

The Florida Office for Insurance Regulation is the state agency charged with insurance administration. Through the Florida Department of Financial Services (DFS), the office also oversees claims administration and settlement per Chapter 627 of the 2021 Florida Statutes. Floridians with questions about insurance claims or those seeking to file complaints of denied claims can use the Online Insurance Assistance webpage. They can also send emails or call the statewide toll-free helpline at (877) 693-5236 to lodge their complaints.

Depending on who initiates an insurance claim, a claim can either be a first-party or a third-party insurance claim. A first-party insurance claim is made by the policyholder. In contrast, a third-party claim is filed by a person or an enterprise other than the insured/policyholder.

Insurance claims triggered by adverse weather conditions are the most common of all claims in Florida. Hail and wind damage account for the highest insurance claims, with an estimated average of $11,000 per claim.

Types of Insurance Claims in Florida

There are five major groups of insurance claims in Florida:

• Property,
• Liability,
• Health,
• Life,
• Business employees.
• Residential insurance claims: Residential property insurance is a type of property and casualty insurance which compensates for property damages. Liability portion of residential insurance allows for claims from non-property owners, if they get hurt while on the insured property. With approximately 65% of all Florida housing units as owner-occupied, approximately 3.5 dwelling units rentals. The subtypes of residential insurance claims in Florida are: Homeowners, Condo, Landlord, and Renters.
• Health insurance: Health insurance claim is filed with the insurer after the medical service is rendered to the insured. Most health insurance claims in Florida are filed by the medical provider, directly with the insurer, without involving the insured.
• Accident and Health insurance claims: Insureds usually file this claim when faced with unplanned medical bills incurred for treating a sickness, injury, or disability, which did not get covered by the health insurance. The payout is usually in the form of a predetermined amount once the conditions are met.
• Automobile insurance claims: An automobile insurance claim comprises personal injury protection (PIP) and property damage liability (PDL). PIP claims cover nearly all medical expenses of at least $10,000, regardless of who caused the car accident. PDL claims, on the other hand, provide minimum coverage of $10,000 for damages to another person’s property when you are at fault in a car accident Of Florida’s 18 million vehicles, 400,000 are involved in crashes annually, and a fourth of which are hit-and-run accidents requiring Uninsured/Underinsured motorist coverage.
• Commercial insurance claims: Business insurance claims, when filed, pay for covered losses experienced in the course of running the businesses. Some of the incidents that prompt filing business insurance claims include bodily injury, property damage, advertising harm, medical expenses, and court/legal fees. A large portion of commercial insurance claims in Florida are liability claims, where the business coverage pays a person for the damages caused to them by the actions of the business.
• Life insurance claims: Life insurance claims are prompted by an insured’s death and provide a death benefit to the policy beneficiaries. Life insurance policy beneficiaries can use death benefits to pay for the funeral, settle the deceased’s debts, and depending on the amount, it can provide an alternative income source for the deceased’s family or a contribution to a charity. The average life expectancy for Florida residents is 80 years old.
• Disaster insurance claims: As a peninsula, Florida is exposed to possible water damage from three directions. Due to this, flood and hurricane insurance claims are the most common among the disaster insurance coverages.
• Long-Term Care insurance claims: These claims reimburse the insured for certain medical and non-medical expenses associated with a major physical/mental disability or a prolonged health condition such as Alzheimer’s disease or stroke
• Disability insurance claims: Disability insurance claims pay a portion of an insured’s wages when a long-term covered injury, accident, or sickness that prevents them from working occurs

How Does an Insurance Claim Work in Florida?

An insured/policyholder can initiate the insurance claim process in the event of a covered loss or damage as stated in their policy document. The insurance company, upon receipt of the insured’s claim for compensation, sends an adjuster to investigate the claim and make recommendations. The insurer then evaluates their adjuster’s recommendations and decides whether to approve the payment of full or partial compensation or to deny the claim.

The Florida insurance market has different insurance types, and each of them has its unique claim process. Regardless of these differences, the steps involved in filing an insurance claim generally include:

• A formal request to an insurer for compensation
• An adjuster’s confirmation of the extent of damage/loss and subsequent review by the insurer to approve or deny the claim
• A formal notice of approval or denial to the claimant
• Receipt of claim payout if approved/Appeal or mediation of claim denial if rejected
• A resort to litigation if appeal and mediation fail

Also, all insurance claims in Florida have a set of common steps that standardize the insurance claim process, and the following terms are used to describe them:

• Timeframe for notice of claim: In Florida, the insured or beneficiary must notify an insurer of their claim within a specified time frame as indicated in their policy document. Although no particular duration is stipulated in the state law, the insured is still required to contact their insurer within a reasonable time after the covered loss has occurred,
• Receipt of notice of claim: Per Florida law (Fla. Stat. 627.70131), an insurer is required to acknowledge receipt of an insured’s claim request within 14 days. This acknowledgment must be written and accompanied by the applicable forms (including a claim form and a proof-of-loss form), instructions, and a phone number,
• Proof of loss: A claimant must submit a written proof-of-loss statement to their insurer within the period indicated in their insurance policy. This document authorizes the insurer to begin investigations and contains the claimant’s sworn oath regarding the extent and details of the damage, loss, or injury,
• Notice of acceptance or denial of claim: In Florida, the insurer must inform the claimant of their approval or rejection of a claim within 90 days, beginning from when they acknowledged the claim notice,
• Time of payment of claims: Per Florida law, an insurer is required to make a claim payment within 90 days from when they acknowledged the claim request or within a reasonable time frame. For instance, a homeowners’ insurer must issue a claim payment within 20 days if they have made a written settlement with the claimant (Fla. Stat. 627.4265),
• Delay in payment of claim: In Florida, an insurer must pay an annual interest of 12% on the claim amount as a penalty if they delay issuing a claim payment within the stipulated time. In addition to the interest penalty, calculated from the time the claim was filed, the insurer may also be liable for the claimant’s attorney and legal fees.

Note that for property and casualty insurance, upon approval of a settlement payout, an insurance carrier must pay the claim in line with the insured’s preferred settlement option. This selection, typically made when purchasing their coverage, allows an insured to receive payment either on the basis of actual cash value or replacement cost. If the claimant is reimbursed with the actual cash value, the claim amount is less because depreciation and the applicable deductible have been deducted. While a replacement cost payout is depreciation-free and is usually recommended as a preferred settlement option since it compensates the claimant with an amount almost equal to the cash value of their home and/or personal property.

How To File an Insurance Claim in Florida?

To file an insurance claim in Florida, an insured must understand their policy coverage, exclusion terms, and policy limits. While certain peculiarities are associated with each type of insurance, a claimant can, nevertheless, follow these general steps to file an insurance claim:

Step 1: Quickly Contact your insurer

Quickly notifying your insurer about the damage suffered after a covered event is essential to obtaining a timely claim settlement. You may also consider reaching your insurance agent for more personalized and responsive service. Alternatively, you can contact your insurer online or by telephone. Most Florida-licensed insurers maintain 24-hour call services through which insureds can contact them or file claims. You must also pay attention to the specific timeframe required for filing your claim as outlined in your policy document to avoid submitting a late claim.

Step 2: Create a detailed record to support your claim

After receiving your claim, it is typical for an insurance company to investigate its authenticity and assess the degree of damage or injury reported. They usually engage their adjuster to conduct the investigation and gather relevant information. It is vital that you compile a detailed record of the damage or loss, including pictures and videos as supporting evidence. For any property insurance claim you need to also correctly specify any lost/damaged personal property by showing the proof of purchase or using a property journal. Similarly, for health and accident insurance, you must provide a complete record of receipts, pharmacy prescriptions, and other relevant medical documents to authenticate your claim. A police report is similarly required for an auto insurance claim along with the driver information, and the insurance information of the at-fault driver. Furthermore, staying close to the adjuster during the investigation can help you reduce the possibility of an error during the investigation.

For property insurance, you must try to maintain the original state of the damaged site/property for proper assessment. You must never rearrange the incident site or make any repair to mitigate further damage without first recording the original condition of the damage. This vital action helps to ensure that the adjuster obtains an accurate record of the original state of damage and that your claim is not undervalued or denied.

Step 3: Obtain an estimate or a bill for compensation

You must provide the insurer with a specific compensation amount, and in Florida, each insurance type has a distinct way of determining this amount. For instance, in property insurance, a reputable property professional can provide you with a personal estimate of the cost of replacing or repairing your damaged property. You can also obtain a auto repair estimate from a professional Florida-registered repair shop in the case of auto insurance and if the other party caused the accident.

This can help you identify any significant variance between the adjuster’s cost estimates and the actual market value. It may also minimize the likelihood of getting your claim undervalued and increase your odds of obtaining a fair settlement. Of course, to do this properly, you must, again, completely understand your insurance policy terms, limits, and coverage exclusions.

If you have any questions about the insurance claims process, speak to your current insurer and/or to a knowledgeable insurance agent licensed to give professional advice in Florida.

How Late Can You File an Insurance Claim?

The required time frame to file an insurance claim in Florida varies based on the specific insurance type. Your insurance policy will typically contain a particular timeline for filing a claim. However, it is advisable to file your claim within a reasonable time. For instance, it is considered late if you file an auto insurance claim after four years following the car accident. This is because the statute of limitations on filing car insurance claims is 4 years from the date of the accident (Fla. Stat. 95.11(3)(a)), and your claim will be dismissed after then, regardless of its validity. The same time frame also applies for homeowners’ insurance when you file a claim, except for a hurricane-related claim, which you must file within 3 years from the storm date.

Can I Cancel My Insurance Claim in Florida?

Yes, you can cancel or withdraw your insurance claim in Florida. You can do so by calling your insurance company’s representative and informing them directly. An insurance claim can be canceled for a range of reasons, such as if the claimant opts to pay for the cost of the damage or loss because it is insignificant. You can also cancel a claim if you wish to avoid paying deductibles and dealing with the chance of increased future insurance premiums. Note, however, that canceling your insurance claim will reflect poorly on your insurance record and may still increase your premium costs in the future.

How Long Do You Have To File an Insurance Claim in Florida?

Under Florida State law, no specific timeframe is stipulated for filing insurance claims. A notable exception exists for auto insurance claims where you must first satisfy the pre-condition of obtaining medical attention within the first 14 days after an accident before you can submit a claim. Health insurance policies also require you to file a claim notice 20 days after the occurrence of a covered event or within any reasonable duration (Fla. Stat. 627.610).

How Long Does an Insurance Company Have To Investigate a Claim in Florida?

Insurance companies that provide property and casualty coverage in Florida are required by law to investigate claims within 90 days after acknowledging receipt of request and proof-of-loss documents. Insurers must complete their investigations within the 30-day window stipulated for PIP claims for auto insurance claims. Generally, insurers must conclude claims investigations within a “reasonable period of time.”

How Long Does an Insurance Claim Check Take?

The specific time required for an insurance company to provide a claim check depends on the type of insurance claim involved. Per Florida State laws, a claimant should collect an insurance claim check within 20 days after the concerned disputing parties have agreed to a written settlement (Fla. Stat. 627.4265). A notable exception exists in the case when both parties have mutually agreed to another settlement date. For example, for auto accident insurance claims (specifically PIP claims), a 30-day period is the legally stipulated duration within which insurers must issue claim checks. The insurer must investigate the claims and notify the claimant of their denial or acceptance within this period. If they, however, fail to issue payment within this legally prescribed period or any other mutually agreed date, they will be liable to pay a 12% interest per annum on the overdue claim payment, which is calculated starting from the settlement date.

Can a Closed Insurance Claim Be Reopened in Florida?

Yes, you can reopen a closed insurance claim in Florida. Claims are often closed when the claimant fails to effectively communicate or respond to an insurer's settlement offer or request for documentation within the legally stipulated time.

However, state law imposes a statute of limitation of between 2-3 years from the date of loss for reopening a closed property claim (Fla. Stat. 627.70132(2)). You may need to hire a professional insurance dispute lawyer or engage the services of a Florida-Licensed insurance agent to assist you with reopening your closed claim.

Can You Cancel an Insurance Claim in Florida?

Yes, you can. An insured can choose to cancel their claim if they believe they can bear the cost of fixing the resulting damages themselves. Canceling your claim will still impact your insurance record, although it may not affect your future premium payments since it is a zero payout record. Insurance carriers do not care if you cancel your claim since they will not have to pay compensation. But you may not be able to do so if any kind of payout has already been made. In auto insurance, you cannot cancel a claim if you are solely responsible for the damages that necessitated the claim in the first place.

You can cancel your insurance claim by contacting your insurer’s representative over the phone while providing your name and claim number. You must also specify your reasons for canceling and verify if you have any paperwork/documentation to fill out to complete the cancelation process.

Can You Keep Insurance Claim Money?

Yes, you can. But it is practically impossible to retain the entire payout amount for certain reasons. For instance, you can keep the claim money if you have made out-of-pocket payments while pursuing your claim settlement. The chances of this happening depend on the type of insurance and the applicable policy terms, and the specific settlement guidelines.

Generally, most insurance companies will pay you directly if there are no policy terms dictating payments for attorney fees and contractor fees. In auto insurance for example, an injured claimant cannot keep a PDL-claim payout made by the at-fault party’s insurer, when their health insurer has already covered their medical expenses. In the absence of a medical bill, the payout will then be applied to repairing or replacing any damaged/destroyed property, if the claimant has not made any out-of-pocket payment.

Another instance is in property and casualty insurance where you and your mortgage lender become joint beneficiaries of the claim payout, if you purchased your home via mortgage financing. Also, depending on the mortgage terms, your lending entity may house the claim amount in an escrow account from which payment for the repairs or replacement of damaged property will be made.

Can a Florida Insurance Company Deny a Claim?

Yes, an insurance company in Florida can deny a claim for various reasons. Although insurance companies exist to indemnify covered losses in exchange for paid premiums, they are also for-profit entities. Consequently, they are usually more thorough when settling large losses or handling numerous claims, even when premiums have been dutifully paid. Insurers always find a way to justify every payout made and often accomplish this by employing adjusters to investigate filed claims.

There are several reasons that can cause an insurance company to deny a claim and some of them are:

• When a covered asset is deliberately damaged or vandalized
• When you file a late claim
• When you lack proper legal representation
• When there are multiple parties at fault
• When you infringe upon Florida State law, such as committing a felony
• When the damage or loss is not clearly covered, or the coverage limits have been exceeded under the policy
• When there is inadequate evidence to support your claim
• When misrepresentations exist in your claim application
• When the cause and extent of damage/loss are not properly established
• When the injuries you sustained are connected with a pre-existing condition

It is vital for you to read through and properly understand what your insurance covers, along with other policy terms and conditions since your insurer will not operate beyond the scope of your policy. To reduce the chances of having your claims denied, you must ensure that all the necessary information, evidence, and records are readily available for evaluation.

What To Do If Insurance Denies Claim

The first step you should take if your insurance carrier denies your claim is to appeal their decision. For instance, auto and property and casualty insurance policies have specific provisions that permit you to contest a denied claim. This is particularly true in situations where you have discovered additional information or new evidence regarding the incident.

If, after an appeal, your insurer still denies your claim, file a complaint with the Florida DFS Consumer Services Division tasked with regulating insurance in the state by calling (877) 693-5236 or online. If all these methods yield no favorable result, you may consider employing the services of an insurance attorney to litigate with your insurer.

How to Settle an Insurance Claim in Florida Without a Lawyer

It is not mandatory to use the services of a lawyer to settle an insurance claim in Florida since it is only one option out of many to resolve a claim. Hiring an attorney to settle an insurance claim may require more time and effort, especially if a property and casualty claim is involved. You can adhere to these steps to increase your chances of getting an adequate claim settlement without any legal representation:

• Obtain free legal advice: Speaking to an attorney before meeting with your insurer’s representative or agent is vital. Most attorneys and law firms are usually willing to offer free consultations and provide vital insurance and legal advice that can help you decide on how best to pursue a claim settlement
• Prepare your claim effectively: Preparation is key and increases your chances of getting compensated. It also helps you to establish a direct and distinct body of proof that undergirds your demand for compensation. Obtain clear photographs and videos of the property damaged in the case of a property and casualty (homeowners) insurance claim. You can also compile a detailed inventory of all damaged properties before and after the damage to ensure that nothing is overlooked. Remember to document every relevant record and receipt connected to the claim because the insurer may contest the validity of your claim in a bid to deny it or reduce the final payout. For health and accident insurance claims, doctor’s reports, police reports, medical records, MRI records, and bills/receipts for various treatments are important evidence to present for your claim.
• File your claim at the appropriate time: You must stick to the right timing stipulated in your specific policy when filing your claim. You risk obtaining an undervalued or a denied claim if you file a late claim. For instance, your auto insurance claim can be denied or undervalued if you file your claim too early or before obtaining medical treatment within the stipulated period. Also, you should wait until any sustained injuries and health conditions have medically stabilized sufficiently enough to determine the full scope of your injury. On the other hand, you must avoid filing your claim after the statute of limitation or any other important policy timeline has expired.

Insurance Denied My Claim Now What?

When an insurance company licensed to operate in the state of Florida denies your claim, you are eligible to appeal the decision or file a lawsuit against them if the appeal fails. However, you must carefully go over the denial notice to understand the reasons for denying your claim. Also, note the procedure and timing for re-filing the claim or appealing the denial.

• Appealing a Denial of Claim Decision: An appeal is essentially a written request by a claimant contesting an insurance company’s decision to deny their claim. If you are convinced that you filed a legitimate claim, consider hiring an insurance attorney to help you with the appeal process and secure compensation.

Typically, some insurance types, such as health insurance, involve a two-step appeal process. First, an internal review where you request for the insurer to conduct a fair and complete review of their decision. If the outcome is not in your favor, an external review is done, and an unbiased third party reviews the claim denial and its reasons. You can pursue litigation if you consider the review outcome unfavorable.

Can an Insurance Company in Florida Deny a Claim?

Yes, an insurance company in Florida can deny a claim for different reasons. Since they are for-profit organizations, their business goal is to make a profit and check unjustified losses. So, insurers generally investigate extensively to avoid settling frivolous claims or, if they must, ensure compensations paid are not overvalued.

Per Florida law, an insured who has either made a late premium payment or missed payment can have their claim denied. Insurance carriers are also permitted to deny an insured’s claim if a material misrepresentation was found in their insurance application. Material misrepresentations are usually those facts that directly impact the insurer’s coverage risk assessment and, if revealed to the insurer, would have resulted in higher insurance premiums or rejection of an application. An insurance company in Florida can also deny a claim for the following reasons:

• The claim is not covered in the specific policy
• The damage or loss is less than the applicable deductible
• The information provided was insufficient to justify claim settlement
• The statute of limitation has expired
• No effort was made to prevent/reduce additional damage or injury
• Errors were identified in the filed insurance claim
• Bad faith on the insurer’s part

NOTE - It is rare for an insurer to deny an insured’s claim whose policy has been in force for more than 90 days and who has always paid their premiums on time.

What to Do If an Insurance Company Denies Your Claim in Florida

First, you must understand that denial is not final and that you have the right to appeal the decision. However, you can only file an appeal within a specified time, and as such, you must scrutinize the denial notice to know the specific directions and deadline set out for the appeal. This notice will also state the insurer’s reasons for denying your claim and whether you are best served by re-submitting the claim or pursuing an appeal.

If your insurance claim is denied, you can opt for the state-sponsored informal alternative dispute resolution programs as provided in Florida Law. This provides the parties involved with an amicable opportunity to resolve their dispute and avoid litigation. A non-partisan mediator from the DFS mediates over this engagement and provides guidance to both the claimant and insurer. The DFS mediator does not insist on any particular outcome, and either party is permitted to reject the outcome of the mediation.

Claimants in Florida can also file complaints of claim denials with the Florida DFS Division of Consumer Services online, by email, or by calling toll-free at (877) 693-5236. If the appeal process fails to yield a claim settlement or results in an under-settlement, you may need to file a lawsuit against the insurer. Obtaining a favorable judgment entitles you to recover the full cost incurred (for court and attorney fees) in pursuing compensation via legal means.

Here are the key takeaways for dealing with denied Florida insurance claim:

• Review the denial notice, paying attention to the reasons for the claim denial, appeal filing procedure, and applicable dates/timelines,
• Partake in the DFS mediation program to explore a less expensive resolution for your denied claim,
• Contact the Florida DFS Division of Consumer Services via its official portals, if you further need to file a claim denial complaint,
• Pursue legal action against your insurer to obtain your desired remedy.